What’s Wrong with this BMD Picture?

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Presentation transcript:

What’s Wrong with this BMD Picture? “Image Not For Diagnosis”: Not a license to not look at the images Steven Burrell Division of Nuclear Medicine

Introduction Bone Mineral Density (BMD) plays an important role in fracture risk assessment and fracture prevention BMD quantitatively measures absorption of photons by bone: a measure of bone density and bone strength Images are also generated not the primary output of the test (unlike most Radiology) Yet the images may contain important information effecting the assessment of bone density and/or fracture risk and sometimes other medical conditions, which may not be known “Image Not for Diagnosis” is not a license to not review the images

This Presentation 12 cases Identify what’s wrong with the images in each case, and how this may effect your assessment of BMD, fracture risk, or the patient’s overall medical care Both hip and spine images are presented abnormality may be on 1 image, or both Some are obvious, some are subtle how will you score?

Case 1 Very high density of the bones in the left hip, L1, and L4 After reviewing the case, click to advance to the discussion. Very high density of the bones in the left hip, L1, and L4 (on images, but see also T-scores) You check PACS for an explanation:

Right femoral neck not involved: Diagnosis? Paget’s Disease Right femoral neck not involved: Patient brought back to perform BMD on right Fracture Risk? - Low risk for fracture from osteoporosis… May be at some increased risk due to the Paget’s: not quantified Bone Scan

Case 2 After reviewing the case, click to advance to the discussion. Very high density of the bones in the spine and pelvis, not femur (on images, but see also T-scores in spine) You check PACS for an explanation:

Diagnosis? Renal Osteodystrophy Fracture Risk? - Low risk for fracture from osteoporosis… However, may be at increased risk due to the renal osteodystrophy: not quantified Teaching Points As with the Paget’s case earlier: Medical conditions (which may be previously unknown!) may contribute to abnormal BMD The fracture risk determined through osteoporosis algorithms may not apply particularly true for multiple myeloma: many get BMD which may yield a low risk for fragility fractures, but they are at high risk for pathologic fractures, especially in the spine

Case 3 L4 appears short and wide: you wonder about a fracture After reviewing the case, click to advance to the discussion. L4 appears short and wide: you wonder about a fracture

No known fracture on requisition or questionnaire BMD Requisition BMD Patient Questionnaire No known fracture on requisition or questionnaire L4 appears short and wide: you wonder about a fracture

Teaching Point A main goal of BMD testing is to assign a fracture risk This patient was moderate risk by BMD and the provided information By evaluating the images, you discovered a spine fragility fracture which elevates the patient to the high fracture risk category  pharmacotherapy indicated You recommend a new radiograph: As suspected: - new fracture of L4 You check PACS: - no fracture 6 months earlier

Case 4 Odd configuration of femoral head and neck After reviewing the case, click to advance to the discussion. Odd configuration of femoral head and neck

- appears very different You check prior BMD 5 years earlier Current - appears very different Technologist’s note:

You check PACS: - 3 months earlier: no fracture You suspect a hip fracture from BMD image and recommend new hip radiographs: - New fractures of femoral head & acetabulum - Fragility fracture of hip:  high risk for future fractures - Needs management for osteoporosis AND immediately for previously unknown fractures Teaching Points While unknown spine fractures are occasionally found, as in prior case, finding an unknown hip fracture is rare… +++ important to the patient

Case 5 2 Relevant Findings: do you see them both? Finding 1: After reviewing the case, click to advance to the discussion. 2 Relevant Findings: do you see them both? Finding 1: Bilateral ureteric stents project over L4 (that counts as 1 finding) L4 should be excluded from analysis (admittedly the overlap is minimal) Finding 2: Unusually high bone density diffusely (images, T-scores) so you check PACS…

diffuse increased uptake in bones Bone Scan Findings? diffuse increased uptake in bones low activity in kidneys & soft tissues:  “Super Scan” CT CT Findings? diffuse sclerosis throughout Diagnosis? metastatic prostate cancer (with bilateral ureteric obstruction) Discussion bone metastases are not uncommon in age range getting BMD testing may not be known: BMD may be first test to discover this confirm with radiographs Bone Scan

Case 6 Densities in RLQ, including over L4 After reviewing the case, click to advance to the discussion. Densities in RLQ, including over L4

Teaching Points Needless to say, metal projecting over bone will artifactually increase BMD Technologist should exclude the lumbar level from analysis Responsibility for the case is ultimately with the radiologist Surgical clips Densities in RLQ, including over L4

Case 7 Densities in RLQ, including over L2 and L3 After reviewing the case, click to advance to the discussion. Densities in RLQ, including over L2 and L3

Teaching Points As per prior case: metal increases perceived BMD levels need to be excluded Densities in RLQ, including over L2 and L3 IVC filter overlies vertebral bodies

A companion case: No subtleties here! LVAD (Left Ventricular Assist Device) and leads overlie upper L-spine

Case 8 After reviewing the case, click to advance to the discussion. Midline gap at L3 + L4 (+ L5, not included in BMD)

Midline gap at L3 + L4 (+ L5, not included in BMD) Laminectomies

excision of posterior elements decreases measured BMD: Teaching Points DXA machines measure an “areal BMD” (g/cm2) based on a 2-D image, not a true volumetric density (g/cm3) this is the density of all bone in the projected area, not just the vertebral body excision of posterior elements decreases measured BMD: lowering the T-score when compared to normal database though true BMD in vertebral body is unchanged these levels should be excluded from the analysis Midline gap at L3 + L4 (+ L5, not included in BMD)

Case 9 Gross abnormalities at hip rotated extra density After reviewing the case, click to advance to the discussion. Gross abnormalities at hip rotated extra density

Gross abnormalities at hip rotated extra density ++ heterotopic bone in paraplegic patient (spinal cord injury)

Paraplegic patients lose bone mass and are at risk for fractures: Teaching Points Paraplegic patients lose bone mass and are at risk for fractures: often undergo BMD testing Assessment of hips can be difficult: difficulty achieving standard positioning heterotopic bone Ultimately hips may not be assessable ++ heterotopic bone in paraplegic patient (spinal cord injury)

Case 10 images are “noisy” After reviewing the case, click to advance to the discussion. images are “noisy” especially in spine, pelvis, & femoral neck, but not more distal femur with curvilinear transition zone

images are “noisy” especially in spine, pelvis, & femoral neck, but not more distal femur with curvilinear transition zone Large pannus overlies femoral neck

DXA = Dual Energy Absorptiometry Teaching Points DXA = Dual Energy Absorptiometry purpose of the 2 energies is to discriminate attenuation by bone from that from soft tissue and thus calculate bone density however, the approach is not perfect, and large amounts of overlying soft tissue can lead to inaccurate results patients should (diplomatically) be asked to lift their pannus upward For the same reason, when patients gain or lose a lot of weight (eg 10%1), comparison of measured BMD to prior may not be valid Large pannus overlies femoral neck (This was a subtle case, but common) 1. Siminoski K et al. Canadian Association of Radiologists Technical Standards for Bone Mineral Density Reporting. CARJ 2013;64:281-294.

Case 11 Rounded densities project over and beside L2 After reviewing the case, click to advance to the discussion. Rounded densities project over and beside L2

Same patient, 2 prior BMD studies Teaching Point As with the previous cases of overlying metal, affected levels should be excluded from the analysis - variable locations: pills - these pills are dense (? calcium)

Case 12 Density traversing upper abdomen, projecting over L1 + L2 After reviewing the case, click to advance to the discussion. Density traversing upper abdomen, projecting over L1 + L2

CT with oral contrast the same day

Teaching Points BMD should be deferred when there has been recent: oral contrast increases measured density Nuclear Medicine study emitted photons can be detected by DXA machine In this case the study went ahead: - L1 + L2 should be excluded

Summary Although primary output of a BMD study is numeric, images are generated The images need to be reviewed: should be second nature for Radiologists You may discover: Artifacts: leading to erroneous: BMD values  fracture risk category  management Important medical conditions: you may be the first to diagnose!